English 
Spanish The Centers for Medicare and Medicaid Services (CMS) defines a workers’ compensation Medicare set-aside as a financial agreement that sets aside part of a workers’ compensation settlement for future medical services. These future medical services must be related directly to the injury that the worker suffered and received a settlement for. A workers’ compensation lawyer can explain more.
Why Should You Create a Workers’ Compensation Medicare Set-Aside?
The purpose of a workers’ compensation Medicare set-aside is to ensure that the compensation received in a settlement for future medical services actually goes toward them. When you file a workers’ compensation claim, you will be awarded a settlement that is meant to cover:
- Lost wages
- Medical costs
If you suffer a long-term disability, or you will need to receive medical treatments for your injury in the future, some of the medical expenses you incur will be for future medical care. If you do not create a Medicare set-aside, you may use your compensation for future medical expenses more quickly than you realize. This could result in Medicare electing not to pay you for damages related to your injury until you hit a specific threshold.
Medicare Is a Secondary Payer
Medicare is a secondary payer, meaning that they only pay for the costs a primary insurer did not cover. Your employer’s workers’ compensation insurance is the primary insurer and should cover you for any injuries you sustain at work. That includes future medical care expenses.
Both you and your employer’s insurance company must keep Medicare’s best interests in mind when it comes to medical expenses and disability insurance. With that, you must that Medicare pays as little as possible, while your employer’s insurance company covers everything else related to your injury.
A workers’ compensation Medicare set-aside provides a way for you and your employer’s insurance company to prove that you keep Medicare’s best interests in mind. Because Medicare has to approve the amount that goes into the set-aside, you will be protected if the fund runs out. Medicare will then pay you for any medical expenses that were not covered in the agreement.
Who Should Create a Workers’ Compensation Medicare Set-Aside?
Creating a workers’ compensation Medicare set-aside is entirely voluntary, though it is recommended for certain individuals. If you meet either of the following criteria provided by CMS, then you should submit a workers’ compensation Medicare set-aside proposal.
- You are a Medicare beneficiary and your total workers’ compensation settlement amount is in excess of $25,000,
- You are expected to enroll in Medicare within 30 months of your settlement date and the total settlement amount for disability and future lost wages is expected to be greater than $250,000.
If you do not meet either of these criteria, you do not need to submit a workers’ compensation Medicare set-aside proposal. The CMS will not review your paperwork.
How Is the Value of a Workers’ Compensation Medicare Set-Aside Determined?
Generally, the value of your workers’ compensation Medicare set-aside will be determined prior to reaching a workers’ compensation settlement. This is to ensure that a proper amount of money is set aside for your future medical needs and to confirm that this compensation properly reflects in your settlement.
To determine the value, Medicare and insurance companies will work together to come up with an amount to cover future medical costs. When Medicare approves a final amount, you will set aside the approved compensation for future use.
How Can a Workers’ Compensation Lawyer Help You With Your Case?
A workers’ compensation or personal injury lawyer can help you determine whether you should set up a workers’ compensation Medicare set-aside. They can explains your options if you do not set up a set-aside, and they can ensure that you are protected in the event that your funds run out.
A lawyer can speak with insurance companies on your behalf and negotiate a fair workers’ compensation settlement agreement. If it is determined that a set-aside is best for you, then during the negotiation process, your lawyer will fight to include future medical expenses in your settlement.
Many workers’ compensation attorneys work on a contingency-fee basis, so they won’t accept any payment unless they recover benefits for you.
Learn More About Whether a Workers’ Compensation Medicare Set-Aside is Right For You
Workers’ compensation Medicare set-asides are complicated. You may not know whether you need one, how to set one up, or how to ensure that you have enough money in your set-aside to cover all future medical expenses associated with your work-related injury.
Rather than try to figure out the entire process yourself, you can hire a workers’ compensation attorney from our firm. They can help you through the entire process, offer guidance and ensure that you make all the right decisions along the way. For more information about Medicare set-aside arrangements, contact KJT Law Group today at (818) 507-8525. We offer free initial consultations.
